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FOR OFFICE-USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------------------- 73_�01 <br /> n� Permit No: - -----------//---- <br /> (y" (Complete in Triplicate) <br /> --------------------------- This Permit Expires 1 Year From Date Issued Date Issued ___.__. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is madein compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA .ION - Z;,------'7 �Y�[��' ----------- ------- -----CENSUS TRACT JY7------------- <br /> ---------------- <br /> Owner's Name 0" ----- ---------f-------------------------------------------- ----------- Phone.----- -- <br /> 1 <br /> Address --------- Cit <br /> Contractor's Name --_ ----------------License # -------.-;-------------- Phone ----------•----------.__--__-- <br /> Installation will serve: Residence,k Apartment House[❑ Commercial ❑Trailer Court i❑ <br /> Motel-❑Other -------------------------------------------- <br /> Number of living units:_________ Number of bedrooms ..--".Garbage Grinder ------------ Lot Size _ .__ _'___________________________ <br /> Water Supply: Public System and name ----------------------•----------•------------------------------_------••_-- ----------------------------------Private E]Character of soil to a depth of 3 feet: Sand' Silt-_1 Clay Peat El —Sand Loam ~Cla Loam <br /> a <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type ____________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells; buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size------------------------------------------------ Liquid Depth .'-------------------------- <br /> Capacity i--------------- Type -------------------- Material---------------------- No. Compartments ---- ................. <br /> Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line __________;___________ <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line-------.-- ------ Total Length _______________ <br /> 'D' Box ...... Type Filter Material --------------------Depth Filter Material ----------.-------------------•---.......... <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line __________________-____. <br /> SEEPAGE PIT [ ] Depth --------I----------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size--------------------------------- <br /> I <br /> Distance to nearest: Well ----------------------------------------Foundation -----------------.-- Prop. Line -.__....__..-.. ...... .+ <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----__--________-__________-_---__) <br /> Septic Tank (Specify Requirements] ---------------- ------:2--------------•------------------------------ <br /> .•------- <br /> Disposal Field (Specify Requirements) -" �*_ ----------- <br /> ----- _ -- _-, ? ,/Yrx+- ------------------------------'---- -----. <br /> �'� " <br /> T -� <br /> -------- <br /> ---- <br /> - <br /> .. <br /> ----------------------------------- ---------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Nome owner or licen- <br /> sed agents signature certifies the following: i <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subjectto Workman's Compensation laws of California." <br /> Signed - �A- - Owner <br /> BY ------------- - --------------------------------- ----------------------------------------------------- Title ------------------- --- <br /> ------------------------------------------------ <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY l <br /> APPLICATION ACCEPTED BY ---- . --" 4� _ 1 A------------------------------------------------------ DATE _i -47_7_73� -•--------•--•--- <br /> BUILDINGPERMIT ISSUED -- ---------- ------------------------------------------------------------------------------------------DATE -------------•--•-------------------------- <br /> ADDITIONALCOMMENTS --------------- ----------------------------------------------------- ----------- ------------------------------------------------------------------ <br /> -------------r---------------------------------------------------------------------------------•----------------------------------------------------- •---- <br /> ----------------- <br /> Final Inspection by: ------------------------- ----- ---- ------ -- -- -- - ---- <br /> ::. =` _ Date ' <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . 9 1 N� <br /> 1". H. -'68 Rev. 5M ' <br />